1 Treatment principles topenlarge
Although these fractures are undisplaced fractures of the greater tuberosity, displacement may occur during the first week or two after injury.
The greater tuberosity fragment tends to be displaced superiorly and posteriorly due to the pull of the rotator cuff (supraspinatus and infraspinatus tendon). If the greater tuberosity heals with displacement, it may impinge upon the coracoacromial arch, limiting motion, and producing pain.
2 Patient preparation and approach topenlarge
This procedure is normally performed with the patient in a beach chair position.
Safe zones for screw insertion
Inserting percutaneous instrumentation through the safe zones reduces the risk of damage to neurovascular structures.
3 Temporary fixation of the greater tuberosity topenlarge
Temporarily fix the fracture with one or more K-wires. Place the K-wire(s) so that they do not hinder subsequent screw insertion.
Confirmation of reduction
Reduction and proper placement of the K-wire should be confirmed by image intensification.
4 Fixation of the greater tuberosity topenlarge
It is the surgeons preference whether to use 3.5 mm cannulated lag screws (as illustrated) or small fragment screws.
Note: Washers might be advisable with osteoporosis or fragmentations. Generally, they are not preferable as they make the screw heads more prominent and may result in shoulder impingement.
If the greater tuberosity fragment is large, two screws may be used for better fixation.
Note: make sure to avoid the axillary nerve by placing the second screw rather proximal.
Once osteosynthesis is completed remove all K-wires.
Check fixation by image intensification.